5 things your dental practice needs to know right now about Medicare

May 20, 2015

Most of the dentists are confused about their Medicare status. They ask each other what options are the best to pursue with no one understanding the ramifications of their choices. 

Most of the dentists are confused about their Medicare status. They ask each other what options are the best to pursue with no one understanding the ramifications of their choices. 

Reading the Medicare website feels like marching through peanut butter. No outside advisor can give you the right answers. Each individual dentist needs to make a choice. Doing nothing is a choice AND action with major ramifications.

So let’s break this down to five things every dentist needs to know now.

1. Dentists are already on the Medicare radar

As a dentist, you have a National Provider Identification (NPI) number … which means Medicare knows you exist. Potentially, thousands of patients will be impacted with the pending Medicare changes. Centers for Medicare and Medicaid Services (CMS) issued a ruling that states if you prescribe medication, perform biopsies that require pathology, or even simply need to refer a patient who is eligible for Medicare to a specialist, you have to make a choice.

By now, most of us have heard the statistics that every single day starting on January 1, 2011, 10,000 Americans turn age 65.That pattern will continue through 2030.

What is the % of Medicare recipients in your state? Those figures are for 2012 … now add 10,000 people per day! This means many patients we have served in the past will start asking you: Will Medicare cover it? The answer to this question is not as simple as you want to think.

How does Medicaid affect the state in which you practice dentistry? Check out our exclusive ranking of every state by clicking here.

2. Ramifications of doing nothing

In the past, dentists did NOT have to declare their status unless they performed medical services (sleep apnea, billing for CT scans, etc.). Now EVERY dentist MUST MAKE A DECISION! Doing nothing is a choice. If you have not declared by either opting out or applying as an approved ordering and referring provider, any Rx written and referrals by you will not be covered by the beneficiary’s Medicare Part D coverage because you are not a recognized provider. Should you refer a patient to another provider for any service you perform that would be covered by Medicare, the service will not be covered. Medicare does not recognize you as the referring provider as opted-out or as enrolled in the registry, therefore there is no coverage.

Scenario of ramifications of the "Do Nothing" mentality for ordering/registry: Rx for Nancy

Nancy, a 54-year-old female, has been a patient of record with Dr. Jones for many years. Based on her multiple health problems and hospitalizations, she is granted a Medicare disability. Nancy presents with a dental abscess, so Dr. Jones writes a script for antibiotics. Nancy is notified by the pharmacy that she must pay out-of-pocket. Medicare will not cover either service because Dr. Jones has not declared any type of status with Medicare.

Outcome of this choice: Nancy is very upset about not having the ability to get the coverage to which she is entitled. She was also told by the pharmacy that Dr. Jones, her dentist, had a choice to get her covered and the dentist chose to do nothing. She is unhappy and surprised because it appears that her dentist did not really care about her. She and her family leave the practice and tell all their friends.

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3. What you need to know if you registered in the past

Some practitioners have registered for Medicare in the past and wonder, “Do I need to do something further?” The answer is yes. If you have previously filled an 855i application and received a Provider Transaction Access Number (PTAN), don't be fooled … you still have some work to do to make sure your PTAN is active.

Why? If you do not submit a claim to Medicare in 12 months, your PTAN will become inactive. You will not be recognized as an active provider, which could potentially the same as the choice to “do nothing” (see previous point).

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4. There are major opportunities for screening for chronic disease in a dental office

The American Dental Association Health Policy Institute (HPI) research shows dental spending in the United States began to slow in 2002, well before the Great Recession and went flat in 2008. With four full years of post-Great Recession data, it is clear that dental spending is not rebounding and has, instead, very likely entered a "new normal." This chart from the ADA shows the many opportunities for dentistry. It’s not time for complacency and playing ostrich. Evaluating options for Medicare and beyond will create a new definition of dentistry and success.

How does Medicaid affect the state in which you practice dentistry? Check out our exclusive ranking of every state by clicking here.

5.    Delayed but only a little

The enrollment deadline was June 1, 2015. However, CMS recently moved the enforcement date to January 1, 2016. Though it feels like, “Whew, I have more time,” delaying your decision is not a good choice. Don't wait until the last minute. Making the choice that best fits your practice and filing the paperwork can take several months. Many providers have signed contracts with dental insurance network providers stating they agree to bill Medicare first for services that meet a medical necessity. If you don't make a decision on what to do about Medicare, this will be a mistake for your practice and can result in loss of patients.

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A Pot of Gold

There can be gold at the end of the rainbow … if you make the right choice for you, your practice, AND your patients!

Editor's Note: This article is an excerpt from the eBook DentalCodeology: What Every Dentist Needs to Know about Medicare NOW by Patti DiGangi, Christine Taxin and Jan Palmer (Sample available.) It has easy to follow examples, links to forms and scenarios to help dentists make an informed decision as to what type of Medicare provider they need to be. The DentalCodeology series of books are easy- to-read bite-size books for busy people to help prepare for the electronic health record transition (more than paperless) profitably by taking what can feel overwhelming into achievable steps. www.DentalCodeology.com.